Acta Oto-Laryngologica, 2012; 132: 1155–1159
Vestibular-evoked myogenic potential in response to bone-conducted
sound in patients with otosclerosis
NAOKI SAKA1, TORU SEO2, KIYOKO FUJIMORI1, YASUO MISHIRO1&
1Department of Otolaryngology, Hyogo College of Medicine, Nishinomiya City, Hyogo and2Department of
Otolaryngology, Osaka Central Hospital, Osaka City, Osaka, Japan
Conclusion: Saccular dysfunction is a major cause of balance problems in patients with otosclerosis. Vestibular-evoked
myogenic potential in response to bone-conducted sound (BC-VEMP) testing is useful for diagnosis of these patients.
Objectives: The purpose of this study was to elucidate the origin of balance problems in patients with otosclerosis using
BC-VEMP. Methods: Subjects comprised 25 patients with unoperated otosclerosis (9 men and 16 women). They were divided
into two groups depending on type of balance problems. Results of cochleo-vestibular functions including pure-
tone audiometry, caloric testing, and BC-VEMP testing were compared between the two groups. Results: Ten patients
had complained of dizziness and/or vertigo (disequilibrium group), and the other 15 patients had not (Non-disequilibrium
group). Nine patients showed abnormal results on BC-VEMP testing in the disequilibrium group, while one patient had
abnormal results in the non-disequilibrium group (p < 0.001).
Keywords: Balance problems, saccular dysfunction, endolymphatic hydrops, direct invasion of otosclerotic focus
Patients with otosclerosis complain of hearing loss or
tinnitus at the early stage of the disease, and the
symptoms worsen progressively. A sclerotic lesion
commonly appears on the anterior part of the oval
window and spreads to the annular ligament of the
stapes, and consequently the stiffness produces con-
ductive hearing loss. It is known that approximately
20–37% of patients have accompanying dizziness
or vertigo [1,2], but the pathogenesis of balance
problems remains unclear.
Conventional vestibular-evoked myogenic poten-
tial (VEMP) was first reported by Colebatch and
Halmagyi in 1992  and has been established as
an examination of otolith function. VEMP is a useful
tool to diagnose balance problems due to otolith
dysfunction, which have not been well studied. As
conventional VEMP is stimulated by air-conducted
sound, it cannot be recorded for patients with con-
ductive hearing loss . Sheykholes et al. revealed
that VEMP response to bone-conducted sound (BC-
VEMP) was recordable for patients with conductive
hearing loss . Welgampola et al. described that
affected ears with inner ear dysfunction showed
abnormal results on BC-VEMP . Miyamoto
et al. reported that results of BC-VEMP are not
significantly different from those of conventional
VEMP . Seo et al. reported that results of
BC-VEMP were abnormal in 54% of patients
with chronic otitis media who complained of
disequilibrium . Thus BC-VEMP can detect
vestibular dysfunction in patients with conductive
Correspondence: Naoki Saka, Department of Otolaryngology, Hyogo College of Medicine, 1-1 Mukogawa-cho, Nisinomiya City, Hyogo, 663-8501, Japan.
Tel: +81 798 45 6493. Fax: +81 798 41 8976. E-mail: email@example.com
(Received 1 April 2012; accepted 11 May 2012)
ISSN 0001-6489 print/ISSN 1651-2251 online ? 2012 Informa Healthcare
We consider that BC-VEMP reveals the origin of
the balance problem in patients with otosclerosis. The
purpose of this study was to elucidate the origin of
balance problems in patients with otosclerosis using
Material and methods
16 women) who were diagnosed with non-operated
otosclerosis and underwent cochleo-vestibular exami-
nations at Hyogo College of Medicine between June
2009 and November 2011 (Table I). The diagnostic
criteria for otosclerosis were based on progressive con-
ductive or mixed-type hearing loss, changes in the
stapedial reflex, and presence of Carhart notch on
audiogram. The mean age was 52.6 years (range, 29–
79 years). Eleven patients had unilateral involvement
into two groups according to the incidence of balance
problems after onset of hearing disturbance due to
otosclerosis: the disequilibrium group (D group), sub-
jects complaining of balance problems; and the non-
disequilibrium group (ND group), subjects without
Cochleo-vestibular function was evaluated by pure-
tone audiometry, caloric testing, and BC-VEMP
testing. Detailed symptoms of balance problems, i.e.
repetition, duration, and inducing factor of symp-
toms were obtained in interviews. Balance problems
Table I. Summary of patients.
AC BCBC-VEMP Balance problems
(years) Sex Side Duration RightLeftRightLeft
CP% RightLeftV or D Duration Recurrence Trigger
1 56FB 1562.5 43.1 28.8 24.43.4 0.00* 0.69D Seconds RecurrentPositional
2 45FL6 9.4 65.6 NM18.1 18.91.620.00*
436FL225.638.823.1 23.1 44.3*1.060.00*DSecondsRecurrent
537FR8 60.031.929.4 24.4
749FB9 65.0 49.444.4 34.4 8.8 0.00* 1.86D Seconds Recurrent Up-and-down
8 44FB 34 105.0 103.867.5 66.3 17.01.301.05VMinutesOnceUp-and-down
960ML2 19.470.66.3 48.1
15 79ML535.665.631.3 46.9 4.20.630.67
20 29FB1035.049.416.9 22.525.0*0.830.74
2252FL422.5 46.916.3 29.40.00.850.90
–4.80.570.00*V + DMinutesRecurrent Up-and-down
2435MB551.956.928.8 23.8 2.31.882.03
2578MB 1592.576.343.1 18.104.22.1680.68
AC, air-conducted thresholds; B, bilateral; BC, bone-conducted thresholds; CP, canal paresis; D, dizziness; Duration, mean duration of
disease; NM, not measured; V, vertigo.
†Past history of benign paroxysmal positional vertigo (BPPV).
N. Saka et al.
were qualified as symptoms after incidence of otos-
clerosis. Results of cochleo-vestibular function testing
and detailed symptoms were compared in the two
Cochlear functions were evaluated with air-conducted
thresholds and bone-conducted thresholds in each ear.
Both thresholds were obtained from averaged hearing
thresholds at the frequencies of 500, 1000, 2000, and
Mono-thermal caloric testing was performed by
stimulation with air at 15?C for 50 s, and evoked
nystagmus was recorded using an FNG1004 electro
nystagmograph (First Co., Tokyo, Japan). The stimu-
lating condition was based on the recommendation by
the Japan Society for Equilibrium Research .
Abnormal results were defined when canal paresis
(CP) was >25% or maximum slow-phase velocity
was <10?/s in both ears.
Detailed measurement of BC-VEMP testing was
performed according to our previous report . To
summarize, bone-conducted stimuli were delivered
with a BR41 bone vibrator (Rion Co., Tokyo, Japan)
placed on the ipsilateral mastoid process of the stim-
ulated ear. Tone burst sound stimuli of 60 dB nHL
(127 dB force level) and 250 Hz (duration, 8 ms; rise/
fall time, 1 ms) were delivered. The myogenic
responses were amplified by bandpass (50 Hz to
3 kHz) filtered with the Neuropack m (Nihon Kohden
Co., Tokyo, Japan), and imported to a personal
computer via analog-digital converter. After normali-
zation with the root mean square value of background
electromyogram during 20 ms before stimuli, the
responses to 100 stimuli were averaged. The subjects
remained in a supine position and were instructed to
turn their head to the opposite side for constant and
strong contraction of the sternocleidomastoid muscle
Results of BC-VEMP were evaluated by the exis-
tence of p13-n23 biphasic wave. When the biphasic
wave was not detected, we considered the result to be
Mann–Whitney U test was used for the analysis of
numerical value categorized by the interval scale
between two groups. Fisher’s exact probability test
was used for analysis of the relationship between the
details of symptoms and the results of BC-VEMP
by 2 ? 2 tables.
The D group was composed of 10 patients and the
ND group was composed of 15 subjects. There were
no significant differences between the D group and
ND group as regards mean age, sex ratio, mean
duration of disease, and unilateral or bilateral involve-
ment (Table II).
The mean air-conducted thresholds in affected ears
in the D group and ND group were 56.3 ± 23.3 and
55.6 ± 17.3 dB, respectively (mean ± SD). There were
no significant differences between the two groups.
Mean bone-conducted thresholds in affected ears of
the D group and ND group were 32.6 ± 16.5 and
29.5 ± 9.5 dB, respectively. No significant difference
was observed between the two groups. Therefore
cochlear function did not relate to the existence of
balance symptoms in patients with otosclerosis.
For caloric testing, 3 of 10 (30%) patients showed
abnormal results in D group, and 1 of 15 (7%)
patients in the ND group. No significant difference
was found between these groups.
In BC-VEMP testing, 9 of 10 (90%) patients in the
D group and 2 of 15 (13%) patients in the ND group
showed abnormal results. A significant difference was
found between the groups (p < 0.001). Abnormal
results were found on the lesion side in all patients
with abnormal results on BC-VEMP. In six of nine
patients in the D group, caloric testing did not show
abnormal results but BC-VEMP did (Table III).
Therefore, balance problems in otosclerosis were
related to abnormal results of BC-VEMP.
Two patients complained of vertigo, seven com-
plained of dizziness, and one patient had both vertigo
and dizziness in the D group. Balance problems were
reported in six patients. The symptoms lasted for
seconds in three patients, minutes in three patients,
hours in three patients and days in one patient. The
symptoms were evoked in six patients. Two patients
Table II. Details of disequilibrium (D) group and
non-disequilibrium (ND) group.
(n = 10)
(n = 15)
Age (years)48.9 ± 9.0 54.3 ± 15.50.319
8.9 ± 9.77.8 ± 5.90.329
Unilateral:bilateral 3:78:7 0.231
BC-VEMP in otosclerosis
complained of positional dizziness and four patients of
disequilibrium during up-and-down movement. The
relationship between detailed balance symptoms and
results of BC-VEMP in the D group are shown
in Table IV.
Results of BC-VEMP for patients with otosclerosis
were previously reported in two papers. Singbartl
et al.  reported 3 patients complaining of dizziness
out of 23 patients with otosclerosis, and all 3 patients
showed normal BC-VEMP. On the other hand, Yang
and Young  reported 5 patients complaining of
vertigo out of 15 patients with otosclerosis, and 2 of
5 (40%) patients indicated absence of BC-VEMP.
The details of balance problems were not described in
either of the latter studies. In the present study,
detailed balance symptoms were obtained by inter-
view, and were compared to results of BC-VEMP. We
showed that 10 of 25 patients complained of balance
problems and 9 of them (90%) showed abnormal
BC-VEMP, thus balance problems were related to
the results of BC-VEMP.
What pathophysiological mechanisms can cause
saccular dysfunction in patients with otosclerosis? We
propose two mechanisms. The first is endolymphatic
hydrops. Many reports have described the relationship
between endolymphatic hydrops and otosclerosis.
with typical signs and symptoms of Meniere’s disease.
Shea et al.  revealed endolymphatic hydrops in five
patients with otosclerosis using electrocochleography.
of endolymphatic hydrops in patients with otosclerotic
endolymphatic duct or sac and malabsorption of fluid
may cause endolymphatic hydrops . In our series,
no patients complained of typical symptoms of
and recurrent vertigo. Seo et al.  reported that
patients with cochleosaccular hydrops revealed by
VEMP did not complain of any recurrent vertigo but
in our series suffered from recurrent disequilibrium
lasting for a short duration (cases 1, 4, and 7). The
symptoms may have originated from saccular hydrops.
The other possibility is direct invasion of the
otosclerotic focus to the saccular macula or saccular
afferent. Igarashi et al.  reported that otosclerotic
invasion had grown close to the utricular and lateral
ampullary nerves by temporal bone study. The dis-
tance from the central areas of the stapedial footplate
to the saccule (1.7–2.1 mm) was shorter than that to
the utricle (1.9–2.4 mm). Furthermore, the distances
in the patients with otosclerosis were shorter than
those in normal subjects , indicating that the
otosclerotic lesion may directly invade the saccule.
What kind of disequilibrium occurs with isolated
saccular dysfunction? Seo et al. studied the symptoms
of patients with normal vestibular function except
for VEMP. They concluded that dizziness with a
sensation of falling lasting for a few seconds was
related to abnormal VEMP results . The symp-
toms are interestingly similar to the above-mentioned
symptoms of saccular hydrops. Also, disequilibrium
Table III. Comparison of results of auditory and vestibular
examination between disequilibrium (D) group and
non-disequilibrium (ND) group.
ExaminationD group ND group
AC (dB) 56.3 ± 23.3 55.6 ± 17.3 0.25
BC (dB) 32.6 ± 16.529.5 ± 9.5 0.482
AC, mean air-conducted thresholds in affected ears; BC, mean
bone-conducted thresholds in affected ears.
Table IV. Relationship between detailed symptoms and results of
Results of BC-VEMP
Vertigo or dizziness
Vertigo and dizziness01
N. Saka et al.
was evoked on an elevator in one of their patients . Download full-text
The up-and-down movement may stimulate the sac-
cule because the polarization vectors of the saccular
macula are placed on the sagittal plane . Thus, the
dizziness evoked by up-and-down head movement
may be caused by saccular dysfunction. In the present
study, four patients suffering from vertigo or dizziness
evoked by up-and-down head movement (cases 7, 8,
18, and 23) might have had saccular dysfunction.
We speculated that the balance problem associated
with otosclerosis is caused by saccular dysfunction
due to otosclerotic involvement. Therefore, hearing
loss may result from cochlear invasion in patients with
balance problems. However, there was no significant
difference between the D group and ND group in air-
conducted and bone-conducted thresholds of hearing
in our study. Singbartl et al.  also found no
correlation between the extent of hearing loss and
VEMP induction. Elonka and Applebaum  sug-
gested that cochlear endosteal involvement alone may
not explain the hearing loss associated with otoscle-
rosis in a temporal bone study. Therefore, we con-
sidered that the balance problem in patients with
otosclerosis is not related to the extent of hearing loss.
Although the origin of balance problems in patients
with otosclerosis is not caused by a single factor, 9 of
10 patients in the D group showed abnormal results
on BC-VEMP testing. Six of them did not show
abnormal results except for BC-VEMP. Therefore,
in our patients, balance problems in otosclerosis were
associated with abnormal results for BC-VEMP. In
other words, saccular dysfunction is a major cause of
balance problems in patients with otosclerosis. We
conclude that BC-VEMP testing is useful for detec-
tion of the origin of balance problems in patients with
Declaration of interest: The authors report no
conflicts of interest. The authors alone are responsible
for the content and writing of the paper.
Gros A, Vatovec J, Sereg-Bahar M. Histologic changes on
stapedial footplate in otosclerosis. Correlations between histo-
Hayashi H, Cureoglu S, Schachern PA, Oktay MF,
Fukushima H, Sone M, et al. Association between cupular
deposits and otosclerosis. Arch Otolaryngol Head Neck Surg
Colebatch JG, Halmagyi GM. Vestibular evoked potentials in
human neck muscles before and after unilateral vestibular
differentiation. Neurology 1992;42:1635–6.
 Ochi K, Ohashi T, Kinoshita H. Acoustic tensor tympani
response and vestibular-evoked myogenic potential. Laryn-
 Sheykholes K, Murofushi T, Kermany MH, Kaga K. Bone-
conducted evoked myogenic potentials from the sternoclei-
domastoid muscle. Acta Otolaryngol 2000;120:731–4.
 Welgampola MS,Rosengren
Colebatch JG. Vestibular activation by bone conducted
sound. J Neurol Neurosurg Psychiatry 2003;74:771–8.
 Miyamoto A, Seo T, Node M, Hashimoto M, Sakagami M.
Preliminary study on vestibular-evoked myogenic potential
induced by bone-conducted stimuli. Otol Neurotol 2006;27:
 Seo T, Miyamoto A, Saka N, Shimano K, Nishida T,
Hashimoto M, et al. Vestibular evoked myogenic potential
induced by bone-conducted stimuli in patients with conduc-
tive hearing loss. Acta Otolaryngol 2008;128:639–43.
 Kitamura K, Koizuka I, Takemori S, Yamamoto T, Ishii M,
Tsuruoka H, et al. Concept of normalization for air
caloric testing (in Japanese). Equilibrium Research 2002;
 Singbartl F, Basta D, Seidl RO, Ernst A, Todt I. Perioper-
ative recordings of vestibular-evoked myogenic potentials in
otosclerosis. Otol Neurotol 2006;27:1070–3.
in patients with otosclerosis using air- and bone-conducted
tone-burst stimulation. Otol Neurotol 2006;28:1–6.
 Paparella MM, Chasin WD. Otosclerosis and vertigo.
J Laryngol Otol 1966;80:511–19.
 Shea JJ, Ge X, Orchik DJ. Endolymphatic hydrops associated
with otosclerosis. Am J Otol 1994;15:348–57.
 Black FO, Sando I, Hildyard VH, Hemenway WG. Bilateral
multiple otosclerotic foci and endolymphatic hydrops. Ann
Otol Rhinol Laryngol 1969;78:1062–73.
 Johnsson LG, Hawkins JE, Rouse RC, Linthicum FH.
Cochlear and otoconial abnormalities in capsular otosclerosis
with hydrops. Ann Otol Rhinol Laryngol 1982;91:3–15.
 Liston SL, Paparella MM, Mancini F, Anderson JH. Oto-
sclerosis and endolymphatic hydrops. Laryngoscope 1984;
 Seo T, Node M, Miyamoto A, Yukimasa A, Terada T,
Sakagami M. Three cases of cochleosaccular endolymphatic
hydrops without vertigo revealed by furosemide-loading ves-
tibular evoked myogenic potential test. Otol Neurotol 2003;
 Igarashi M, Jerger S, O-uchi T, Alford BR. Fluctuating
hearing loss and recurrent vertigo in otosclerosis. Arch Oto-
 Pauw BKH, Pollak AM, Fisch U. Utricle, saccule and
cochlear duct in relation to stapedotomy. Ann Otol Rhinol
 Seo T, Miyamoto A, Node M, Sakagami M. Vestibular
evoked myogenic potentials of undiagnosed dizziness. Auris
Nasus Larynx 2008;35:27–30.
 Fernandez C, Goldberg JM. Physiology of peripheral neu-
rons innervating otolith organs of the squirrel monkey. I.
Response to static tilts and to long-duration centrifugal force.
J Neurophysiol 1976;39:970–84.
 Elonka DR, Applebaum EL. Otosclerotic involvement of the
cochlea: a histologic and audiologic study. Otolaryngol Head
Neck Surg 1981;89:343–51.
BC-VEMP in otosclerosis